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Introduction and Background¹

Pain is a leading cause of disability globally (Dahlhamer et al., 2018; Vos et al., 2015). The dramatic increase in opioid prescriptions within the past decade in the United States has contributed to the opioid epidemic the country currently faces, magnifying the need for longer term solutions to treat pain (Rudd et al., 2016). The substantial burden of pain and the ongoing opioid crisis have attracted increased attention in medical and public policy communities, resulting in a revolution in thinking about how pain is managed, said Daniel Cherkin, senior investigator (emeritus) at the Kaiser Permanente Washington Health Research Institute. This new thinking acknowledges the complexity and biopsychosocial nature of the pain experience and the need for multifaceted pain management approaches with both pharmacological and nonpharmacological therapies, a recommendation of the 2011 Institute of Medicine report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (IOM, 2011b) and the National Academies report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (NASEM, 2017).

For example, Cherkin said the American College of Physicians recently recommended a dramatically new approach to managing back pain that begins with nonpharmacological treatments as first-line care (Qaseem et al., 2017). Nonpharmacological approaches are also emphasized in the

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¹ The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.

Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain (Dowell et al., 2016), added Steven George, professor and director of musculoskeletal research at the Duke Clinical Research Institute. An important challenge is to find strategies to implement these guidelines effectively and efficiently in real-world practice, said Cherkin. Echoing the emphasis on implementation, Anthony Delitto, dean of the School of Health and Rehabilitation Sciences and professor of physical therapy at the University of Pittsburgh, added that implementing what is known now could make a big dent in addressing the challenges associated with pain management. Emerging models of care that provide integrated, patient-centered, evidence-based, multimodal, interdisciplinary care,² with systematic coordination of medical, psychological, and social aspects of care—a concept promoted by the National Pain Strategy—have been shown to decrease pain and increase function and will be important, said Robert Kerns, professor of psychiatry, neurology, and psychology at Yale University.

The magnitude and urgency of the twin problems of chronic pain and opioid addiction, combined with the changing landscape of pain management, prompted the National Academies of Sciences, Engineering, and Medicine’s Forum on Neuroscience and Nervous System Disorders and its Global Forum on Innovation in Health Professional Education to convene a workshop on December 4–5, 2018, in Washington, DC. The workshop brought together a diverse group of stakeholders to discuss the current status of nonpharmacological approaches to pain management, gaps, and future directions.

WORKSHOP OBJECTIVES

The workshop was designed to provide participants with an understanding of the evidence currently available on the effectiveness and safety of nonpharmacological approaches to pain management, as well as information about emerging models of care for people living with chronic pain. In addition, the workshop explored barriers, opportunities, and policy changes needed to facilitate implementation of integrated systems of care that include nonpharmacological treatments (see Box 1-1). Workshop

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² Defined in the National Pain Strategy as care provided by a team of health professionals from diverse fields who coordinate their skills and resources to meet patient goals.

presentations primarily focused on chronic pain.³ There was limited discussion of natural products (e.g., cannabis and vitamins)—an examination of their effectiveness as treatments for pain was not within the scope of the workshop.

ORGANIZATION OF THE PROCEEDINGS

Chapter 2 provides context to the workshop, including perspectives from people living with pain and from providers about how pain is currently managed, and opportunities to reduce disparities. Chapter 3 examines the evidence available for nonpharmacological approaches to pain management and discusses future research priorities identified by individual workshop participants. Emerging models of care, including stepped, stratified, integrative, and multimodal care models, as well as the use of technology to encourage self-management, are discussed in Chapter 4. Chapter 5 highlights major current research initiatives supported by federal agencies and a nongovernmental institute in the United States that focus on pain management and reducing opioid use. Gaps in the education and training of health professionals in pain management are discussed in Chapter 6, along with opportunities to address these gaps within and across health professions to encourage the adoption and appropriate use of evidence-based approaches. Chapter 7 explores potential policy solutions to address barriers to the delivery of effective pain care. In Chapter 8, workshop participants consider potential next steps needed to advance the integration of evidence-based nonpharmacological approaches in pain care.

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³ For an in-depth discussion about pain management for people with serious illness, see the forthcoming proceedings from the complementary workshop on Pain and Symptom Management for People with Serious Illness in the Context of the Opioid Epidemic, hosted on November 29, 2018, by the National Academies’ Roundtable on Quality Care for People with Serious Illness. For more information, see http://nationalacademies.org/hmd/activities/healthservices/qualitycareforseriousillnessroundtable/2018-nov-29.aspx (accessed February 9, 2019).